7. PROJECT SUMMARY Reducing access to highly lethal methods of suicide?especially firearms?can save lives. Counseling about how to reduce lethal means access (lethal means counseling, LMC) is recommended for people at risk of suicide but often does not occur in busy clinical settings like emergency departments (EDs). By using respectful, acceptable messaging, a patient-centered firearm lethal means decision aid (LM-DA) could augment current care by educating and enabling at-risk patients and their family or friends to enhance home safety. This R34 proposal builds on preliminary work and is a stepping stone towards a subsequent large-scale trial. Over a two-year period, the multi-disciplinary study team aims to (1) develop and (2) conduct preliminary testing on an innovative, web-based intervention with the potential for future widespread implementation and dissemination. The underlying hypothesis is that the LM-DA will be acceptable to stakeholders, effective in enhancing patient-centered decision-making around home firearm access during times of suicide risk, as well as feasible to use and to study in a subsequent hybrid effectiveness-implementation trial. In this R34, the study team will first complete a web-based LM-DA to optimize ?fit? for suicidal adults, with the decision being ?which options to choose to reduce home access to firearms.? The process will follow international standards, using iterative refinement and testing with stakeholder groups and then website development and testing. Next, in a pilot randomized controlled trial, the team will assess acceptability, feasibility and effects of LM-DA use among patients and providers, as well as feasibility of a subsequent trial. Specifically, in a patient-level randomized controlled trial in three EDs of adult patients with SI/SA (n=60 total) in three EDs, the study will examine: (1) the LM-DA (feasibility and acceptability); (2) preliminary effects on decision-making (knowledge, decision conflict, and values concordance); (3) effect on home firearm storage (exploratory); (4) effect on suicide outcomes (exploratory); and (5) feasibility of conducting a subsequent, large-scale trial. Patient enrollment will be complemented by enrollment of one family member or friend per patient, as well as by surveys and interviews with providers in the three participating EDs. The proposed research will provide the scientific foundation for improvement and examination of real-word implementation of an effective, patient-centered LM- DA in EDs and other settings. A web-based tool offers the potential to significantly enhance current care, decrease real-world access to lethal means of suicide, and thereby decrease short-term risk of suicide.